Download Brief Report Midaxillary lateral thoracotomy for closure of atrial

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Cardiol Young 2003; 13: 565–567
© Greenwich Medical Media Ltd.
ISSN 1047-9511
Brief Report
Midaxillary lateral thoracotomy for closure of atrial septal
defects in pre-pubescent female children: reappraisal of
an “old technique”
Christian Schreiber, Sabine Bleiziffer, Rüdiger Lange
Clinic of Cardiovascular Surgery, German Heart Center Munich at the Technical University, Munich, Germany
Abstract Our long-term follow-up has revealed that symmetrical development of the breasts is significantly
impaired in pre-pubescent female patients subsequent to an anterolateral thoracotomy. Although standard posterolateral and anterolateral right-sided thoracotomies are used for correction of “simple” cardiac lesions such
as patency of the arterial duct, coarctation of the aorta, or atrial septal defect, the required partial transection of
large muscle groups, and injury to the developing tissues of the breast, may contribute to an unfavourable cosmetic outcome. Over the years, many surgeons, mostly specialising in thoracic procedures, have advocated
mini- or axillary thoracotomies. In an attempt to improve surgical and cosmetic outcome, we have now adopted
such a muscle-sparing approach, using a small horizontal midaxillary incision. We have now successfully
employed the technique to close atrial septal defects in the oval fossa in 17 pre-pubescent females.
Keywords: Minimal invasive cardiac surgery; posterolateral thoracotomy; anterolateral thoracotomy
S
TANDARD POSTEROLATERAL AND ANTEROLATERAL
right-sided thoracotomies have now gained general acceptance as the standard surgical approaches
in correction of “simple” cardiac lesions such as persistent patency of the arterial duct, cooarctation of the
aorta, and atrial septal defect in the oval fossa. These
approaches are considered minimally invasive, since
they avoid median sternotomy, and help to improve
the cosmetic result. The division or incision of the
latissimus dorsi, serratus anterior, or pectoralis muscles,
nonetheless, produces significant trauma to the chest,
and may cause substantial perioperative morbidity and
long-term disability.1–3 Because of this, thoracic surgeons have described the use of limited thoracotomies.4–6 More recently, Yang et al.7 have described
their results using such a technique in combination
with cardiopulmonary bypass.
With this in mind, we describe here our own modification of the technique used in patients undergoing an anterolateral thoracotomy whilst below the
Correspondence to: Christian Schreiber MD, German Heart Center Munich,
Clinic of Cardiovascular Surgery at the Technical University, Lazarettstrasse 36,
80636 Munich, Germany. Tel: 0049 (0)89 12184111; Fax: 0049 (0)89
12184113; E-mail: [email protected]
Accepted for publication 18 August 2003
age of 12 years at the time of operation.8 So as to
avoid impaired development of the breasts, we have
successfully employed the modified midaxillary technique in 17 patients undergoing closure of an atrial
septal defect in the oval fossa between the ages of 4
and 12 years.
Technique
The patient is placed in an anterior oblique position
at an angle of 45°, and the arm is suspended at a right
angle. The skin incision is performed near the midaxillary line. It begins at the height of the mammary
areola, and passes posteriorly towards the tip of the
scapula, ranging in length from 5 to 6.5 cm. Although
the latissimus dorsi muscle inserts on the posterior
aspect of the iliac crest, in the lateral position the
anterior margin is usually found on the line between
the posterior axillary fold and the anterior-superior
iliac spine. The subcutaneous attachments of the
latissimus dorsi muscle are mobilized with electrocautery by dissecting just superficial to the fascia.
The entire anterior border of the muscle is thus freed.
The muscle can now be retracted posteriorly, exposing
the serratus anterior muscle. This muscle is dissected
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sutures are placed, and the muscles are allowed to
return to their normal position. Single sutures can be
placed on the posterior border of the serratus muscle,
and another on the anterior border of the latissimus
muscle, thus anchoring them to the surrounding fascia.
Figure 1.
The exposure of the lateral aspect of the right side of the heart
achieved through the midaxillary thoracotomy.
by dividing the fascia along its posterior border up
to, and just above, the tip of the scapula, and down to
the lowest attachment on the anterior aspect of the
sixth rib. The muscle is retracted forward. The thorax
is opened in the bed of the fourth rib. The heart is
exposed adequately by opening the pericardium, and
placing suitable stay sutures (Fig. 1). Tapes are passed
around the caval veins. Two standard purse-string
sutures are placed on the ascending aorta, and direct
cannulation is performed. We have used “Medtronic”
DLP® cannulas. After placing standard purse-string
sutures at the junctions of the caval veins with the
right atrium, we perform bicaval cannulation using
straight cannulas, currently employing wire-reinforced
cannulas from Stöckert®. The use of angled cannulas
may also be considered. We have not used femoral or
iliac cannulation in any patient in our series. Cardiopulmonary bypass is instituted. The caval venous tapes
are snared, the right atrium is opened under normothermia, and fibrillation is induced electrically. We
perform a vertical incision in the mid portion of the
atrium, believing this to facilitate subsequent closure
after the modified thoracotomy in contrast to the
primary standard oblique atrial incision. Two sump
suckers, of which one is placed in the coronary sinus,
allow clear exposure of the right atrial cavity. The
intraatrial defect is either closed with direct suture or
patch material. The pericardial stay-sutures are then
removed before gradually inflating the lungs for
de-airing. With a needle and a syringe, blood is withdrawn from the pulmonary veins, or directly from the
left atrium and the ascending aorta. The operating
table is then rotated, keeping down the head of the
patient, and the heart is defibrillated. After a short
period of reperfusion, the patient is weaned from
bypass. To close, the retractors are removed, pericostal
Discussion
Considerable discussion continues, not only between
thoracic surgeons but also cardiac surgeons, regarding
the merits of different thoracotomies. It is accepted that
standard posterolateral or anterolateral thoracotomy
incisions provide good exposure of the intrathoracic
structures. In cardiac surgery, these lateral thoracotomies are used in children9,10 as an alternative access
to anterior approaches such as full sternotomy, ministernotomy, or the transxyphoid approach. Despite
their popularity, the advocates of the muscle-sparing
alternatives claim that acute and late pain, and morbidity, are reduced.1–3 Thoracic surgeons have long
considered the axillary thoracotomy as an optimal
approach for pulmonary and mediastinal lesions.4-6
We claim no originality in describing our current approach, wishing only to highlight the possible
advantages of a midaxillary thoracotomy that spares
the major groups of external muscles. Furthermore, in
contrast to the anterolateral approach, the midaxillary
approach helps to hide the scar within axillary region
when used in pre-pubescent females. In this subgroup of patients, the submammary grooves are not yet
defined, thus presenting a problem in determining
the exact position of the desired incision. The midaxillary incision is not even close to the future tissues of
the breast, a fact that should avoid with certainty any
impairment of mammary development (Fig. 2). Apart
from the intercostal musculature, the approach obviates the need to divide or incise any other muscles.
We have preferred to use a short horizontal midaxillary incision in the skin, as this does not compromise
any axillary glands, and does cross Langer’s lines in
perpendicular fashion.
Especially today, where percutaneous closure of an
atrial septal defect is becoming an accepted technique
using catheters, substantial scaring or deformity needs
to be avoided after any surgical intervention. Our
described approach may represent a useful alternative. The technique we describe, nonetheless, is by no
means “standard”. It requires not only thorough preoperative assessment of the nature of the interatrial
communication, ensuring that it is within the oval
fossa, but also requires that both the surgeon and the
anaesthetist are experienced in minimal invasive surgery. The primary goal of this alternative approach,
in our mind, is the avoidance of trauma to the future
tissues of the breast, and midline scarring. The surgeon,
however, must be fully acquainted with both the
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References
Figure 2.
The early postoperative result after using the muscle-sparing thoracotomy in a female patient aged 4 years and weighing 14.8 kg.
surgical access and the technical aspects described, since
the safety of an elective operation in an otherwise
healthy patient must not be jeopardized by the introduction of procedures foreign to daily practice.
1. Landreneau RJ, Pigula F, Luketich JD, et al. Acute and chronic
morbidity differences between muscle-sparing and standard lateral
thoracotomies. J Thorac Cardiovasc Surg 1996; 112: 1346–1351.
2. Bendetti F, Vighetti S, Ricco C, et al. Neurophysiologic assessment of nerve impairment in posterolateral and muscle-sparing
thoracotomy. J Cardiovasc Surg 1998; 115: 841–847.
3. Nomori H, Ohtsuka T, Horio H, Naruke T, Suemasu K. Difference in the impairment of vital capacity and 6-minute walking
after a lobectomy performed by thoracoscopic surgery, an anterior
limited thoracotomy, an anteroaxillary thoracotomy, and a posterolateral thoracotomy. Surg Today 2003; 33: 7–12.
4. Noirclerc M, Dor V, Chauvin G, et al. Extensive lateral thoracotomy without muscle section. Ann Chir Thorac Cardiovasc 1973;
12: 181–184.
5. Becker RM, Munro DD. Transaxillary minithoracotomy: the
optimal approach for certain pulmonary and mediastinal lesions.
Ann Thorac Surg 1976; 22: 254–259.
6. Mitchell R, Angell W, Wuerflein R, Dor V. Simplified lateral chest
incision for most thoracotomies other than sternotomy. Ann Thorac
Surg 1976; 22: 284–286.
7. Yang X, Wang D, Wu Q. Repair of atrial septal defect through
a minimal right vertical infra-axillary thoracotomy in a beating
heart. Ann Thorac Surg 2001; 71: 2053–2954.
8. Bleiziffer S, Schreiber C, Burgkart R, et al. Impaired development
of the right mamma after right anterolateral thoracotomy in prepubescent female patients. Cardiol Young 2003; 13 (Suppl 1): 86.
9. Giamberti A, Mazzera E, Di Chiara L, Ferretti E, Pasquini L,
Di Donato RM. Right submammary minithoracotomy for repair
of congenital heart defects. Eur J Cardio-thorac Surg 2000; 18:
678–682.
10. Yoshimura N, Yamguchi M, Oshima Y, Oka S, Ootaki Y, Yoshida M.
Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients. Ann Thorac Surg
2001; 72: 2103–2105.